Membrane Oxygenation Cardiopulmonary Resuscitation Research Articles

Quality improvement developments following pediatric resuscitation and veno-arterial extracorporeal membrane oxygenation support due to a massive intentional antidepressant overdose

Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation (ECPR) is the act of placing a patient on bypass at the bedside while simultaneously carrying out life-sustaining interventions such as chest compressions or epinephrine administration. This involves a team of physicians, nurses, respiratory therapists, pharmacists, extracorporeal membrane oxygenation (ECMO) trained staff, and other health professionals who must focus on cardiopulmonary resuscitation (CPR), cannulation, and initiating ECMO flow at the same time. ECPR may be considered when traditional CPR does not achieve return of spontaneous circulation (ROSC) in a patient. Limitations when thinking about using ECPR for a patient include location, timing from arrest to CPR initiation, as well as CPR initiation to successfully on bypass, trained staff available to begin the cannulation process, and pauses in compressions during surgery. We analyzed a pediatric patient who required ECPR after an intentional drug overdose. Gaps identified in this case prompted us to assess our ECPR protocol. Through the development and use of multidisciplinary ECPR simulations, our team discovered areas of quality improvement and put those findings into practice.

Potential role for extracorporeal membrane oxygenation cardiopulmonary resuscitation (E-CPR) during in-hospital cardiac arrest in Australia: A nested cohort study

ObjectiveThis study aims to evaluate the characteristics and outcomes of patients who fulfilled extracorporeal membrane oxygenation cardiopulmonary resuscitation (E-CPR) selection criteria during in-hospital cardiac arrest (IHCA). DesignThis is a nested cohort study. SettingCode blue data were collected across seven hospitals in Australia between July 2017 and August 2018. ParticipantsParticipants who fulfilled E-CPR selection criteria during IHCA were included. Main outcome measuresReturn of spontaneous circulation and survival and functional outcome at hospital discharge. Functional outcome was measured using the modified Rankin scale, with scores dichotomised into good and poor functional outcome. ResultsTwenty-three (23/144; 16%) patients fulfilled E-CPR selection criteria during IHCA, and 11/23 (47.8%) had a poor outcome. Patients with a poor outcome were more likely to have a non-shockable rhythm (81.8% vs. 16.7%; p = 0.002), and a longer duration of CPR (median 12.5 [5.5, 39.5] vs. 1.5 [0.3, 2.5] minutes; p < 0.001) compared to those with a good outcome. The majority of patients (18/19 [94.7%]) achieved sustained return of spontaneous circulation within 15 minutes of CPR. All five patients who had CPR >15 minutes had a poor outcome. ConclusionApproximately one in six IHCA patients fulfilled E-CPR selection criteria during IHCA, half of whom had a poor outcome. Non-shockable rhythm and longer duration of CPR were associated with poor outcome. Patients who had CPR for >15 minutes and a poor outcome may have benefited from E-CPR. The feasibility, effectiveness and risks of commencing E-CPR earlier in IHCA and among those with non-shockable rhythms requires further investigation.

Interprofessional Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation Simulations Aimed at Decreasing Actual Cannulation Times: A Longitudinal Study.

Since 2013, the cardiac intensive care unit (CICU) at Children's National has conducted annual extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR) simulations that focus on team dynamics, room setup, and high-quality CPR. In 2019 and 2020, the simulations were expanded to include the surgical and extracorporeal membrane oxygenation (ECMO) teams in an effort to better understand and improve this process. During a 4-week period in 2019, 7 peripheral ECPR simulations were conducted, and through a 3-week period in 2020, 7 central ECPR simulations were conducted. Participants in each session included: 8 to 10 CICU nurses, 1 CICU attending, 1 to 2 ICU or cardiology fellows, 1 cardiovascular surgery fellow or attending, and 1 ECMO specialist. For each session, the scenario continued until the simulated patient was on full cardiopulmonary bypass. An ECMO trainer was used for peripheral simulations and a 3-dimensionally-printed heart was used for central cannulations. An ECMO checklist was used to objectively determine when the patient and room were fully prepared for surgical intervention, and simulated cannulation times were recorded for both groups. A retrospective chart review was conducted to compare actual cannulation times before and after the intervention period, and video was used to review the events and assist in dividing them into medical versus surgical phases. Control charts were used to trend the total ECPR times before and after the intervention period, and mean and P values were calculated for both ECPR times and for all other categorical data. Mean peripheral ECPR times decreased significantly from 71.7 to 45.1 minutes ( P = 0.036) after the intervention period, and this was reflected by a centerline shift. Although we could not describe a similar decrease in central ECPR times because there were only 6 postintervention events, the times for each of these events were shorter than the historical mean of 37.8 minutes. There was a trend in improved survival, which did not meet significance both among patients undergoing peripheral ECPR (15.4% ± 10% to 43.8% ± 12.4%, P = 0.10) and central ECPR (36.4% ± 8.4% to 50% ± 25%, P = 0.60). The percentage of time dedicated to the medical phases of the actual versus simulated procedures was very consistent among both peripheral (33.0% vs. 31.9%) and central (39.6% vs. 39.8%) cannulations. We observed a significant decrease in peripheral cannulation times at our institution after conducting interprofessional ECPR simulations taken to the establishment of full cardiopulmonary bypass. The use of an ECMO trainer and a 3-dimensionally-printed heart allowed for both the medical and surgical phases of the procedure to be studied in detail, providing opportunities to streamline and improve this complex process. Larger multisite studies will be needed in the future to assess the effect of efforts like these on patient survival.

Long-Term Survival and Quality of Life in Non-Surgical Adult Patients Supported with Veno-Arterial Extracorporeal Oxygenation.

The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for hemodynamic support is on the rise. Not much is known about the impact of extracorporeal membrane oxygenation (ECMO) and its complications on long-term survival and quality of life. In this single-center, cross-sectional study, we evaluated the survival and quality of life in patients treated with VA ECMO between May 2009 and July 2019. Follow-up was conducted between November 2019 and January 2020. Overall, 118 patients were evaluated in this study. Of the 37 patients who were alive at hospital discharge, 32 answered the EuroQol-5 dimensional-5-level questionnaire (EQ-5D-5L). For patients discharged alive from the hospital, mean survival was 8.1 years, 8.4 years for cardiogenic shock, and 5.0 years for patients with refractory cardiac arrest. EQ-5D-5L index value of ECMO survivors was not significantly different from the general age-matched population. Neurologic complications and major bleeding during index hospitalization limit long-term quality of life. Patients treated with VA ECMO have high in-hospital mortality, with extracorporeal membrane oxygenation cardio-pulmonary resuscitation patients being at higher risk of early death. However, once discharged from the hospital, most patients remain alive with a reasonable quality of life.

Role of the emergency department in implementing an extracorporeal membrane oxygenation cardiopulmonary resuscitation.

The Royal Brisbane and Women's Hospital has introduced an extracorporeal membrane oxygenation (ECMO) cardiopulmonary resuscitation (E-CPR) service with collaboration between ED and ICU teams for refractory cardiac arrest patients. E-CPR is potentially beneficial to patients who do not gain return of spontaneous circulation after conventional advanced cardiac life support treatments, provided specific demographic and biochemical inclusion criteria are met. A joint ICU and ED decision is reached to commence ECMO flow. We discuss our rationale to use the ED and the emergency physician role in leading the multidisciplinary team, with ICU leading the cannulation team. The development of ED processes and the increased availability of this intervention can significantly impact the survivability of refractory cardiac arrest with good neurological outcomes.

Cardiac Catheter Laboratory Utilisation Following Introduction of an Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation (e-CPR) Programme for Out-of-Hospital Cardiac Arrest

Refractory out-of-hospital cardiac arrest (r-OHCA) is associated with globally poor outcomes. Highly selected r-OHCA cases may be suitable for invasive, resource intensive interventions such as extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR). We sought to further understand whether ECPR implementation would have unintended effects on cardiac catheterisation laboratory (CCL) utilisation. This was an analysis of a prospective adult OHCA registry and Utstein-based outcome reporting with two distinct ‘pre’ and ‘post’ cohorts. The setting was a tertiary centre in Sydney, Australia. The pre-ECPR cohort comprised consecutive OHCA patients between 2016 and 2019 (prior to an ECPR program), and the post-ECPR cohort from mid-2020 and mid-2021 (post implementation of an ECPR program). There were 248 patients in the pre-ECPR cohort and 51 in the post-ECPR cohort. The groups had similar baseline characteristics. Sustained return of spontaneous circulation (ROSC) was obtained in 61 (24.6%) (pre) and 12 (23.5%) (post) OHCAs, respectively (p=0.86). Pre-ECPR, 47 (77%) received CCL during admission versus 8 (67%) post-ECPR (p=0.55). Early CCL (<24 h) was performed in 34 (56%) pre-ECPR patients versus 8 (67%) post-ECPR (p=0.57). In patients receiving early CCL, time from OHCA to CCL arrival was 188.38 min (SD 176.6) for pre-ECPR versus 130.38 min (SD 91.9) for the post-ECPR cohort (p=0.38). ECPR was attempted in 6/51 OHCA cases but only 1 patient survived to CCL. ECPR implementation did not appear to lead to unintended delayed to CCL interventions. All patients attending CCL post-ECPR implementation did so within 24 hours [[1]Yannopoulos D. Bartos J. Raveendran G. Walser E. Connett J. Murray T.A. et al.Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial.Lancet. 2020; 396: 1807-1816Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar].

Potential Role for Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation (E-CPR) Following In-Hospital Cardiac Arrest in Australia: A Nested Cohort Study

Potential Role for Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation (E-CPR) Following In-Hospital Cardiac Arrest in Australia: A Nested Cohort Study

Feasibility of extracorporeal membrane oxygenation cardiopulmonary resuscitation by low volume centers in Belgium.

ObjectiveTo assess the feasibility of delivering extracorporeal cardiopulmonary resuscitation (ECPR) in refractory out‐of‐hospital cardiac arrests (OHCA) by low volume extracorporeal membrane oxygenation (ECMO) centers and to explore pre‐ECPR predictors of survival.MethodsBetween 2016 and 2020, we studied 21 ECPR patients admitted in 2 tertiary ECMO centers in Liège, Belgium. Our ECPR protocol was based on 6 prehospital criteria (no flow < 3 minutes, low flow < 60 minutes, initial shockable rhythm, end‐tidal CO2 > 15 mmHg, age < 65 years, and absence of comorbidities). A dedicated training, prehospital checklist and call number for 24/7 ECMO team assistance were implemented. Hemodynamics and blood gases on admission also were assessed.ResultsTwenty‐one (28%) out of 75 refractory OHCA patients referred were treated by ECPR, with a hospital survival rate of 43% (n = 9/21), comparable to ECPR results from the international extracorporeal life support organization registry. Transient return of spontaneous circulation before ECPR (89% in survivors vs 17% in non‐survivors, P = 0.002) and higher initial serum bicarbonate (med [P25‐P75] 14.0 [10.6–15.2] vs 7.5 [3.7–10.5] mmol/L, P = 0.019) or lower initial base deficit (14.9 [11.9–18.2] vs 21.6 [17.9–28.9] mmol/L, P = 0.039) were associated with a more favorable outcome.ConclusionIn low volume ECMO centers, the implementation of a specific ECPR protocol for refractory OHCA patients is feasible and provides potential clinical benefit. Highly selective inclusion criteria seem essential to select candidates for ECPR. Initial serum bicarbonate and base deficit integrating cumulative cell failure may be relevant pre‐ECMO prognostic factors and require larger‐scale evaluation.

Obesity is not a contraindication to veno-arterial extracorporeal life support.

Obesity may complicate the peripheral cannulation and delivery of veno-arterial extracorporeal life support (ECLS). With rising global body mass indices (BMI), obesity is becoming increasingly prevalent in severe cardiogenic shock yet its impact on outcomes is not well described. This study sought to examine the relationship between BMI and veno-arterial ECLS outcomes to better inform clinical decision-making. All cardiogenic shock patients undergoing peripheral veno-arterial ECLS at our institution from March 2008 to January 2019 were retrospectively analysed (n = 431). Patients were divided into 4 groups, BMI 17.5-24.9, 25-29.9, 30-34.9 and ≥35 kg/m2, and compared on clinical outcomes. Multivariable logistic regression was performed to identify variables associated with survival to discharge, the primary outcome of interest. The median BMI was 28.3 kg/m2 (interquartile range 24.8-32.6) with a range of 17.0-69.1 kg/m2. Obese patients achieved significantly lower percentages of predicted flow rates compared with BMI < 25 kg/m2 patients though did not differ in their lactate clearances. Patients with BMI ≥35 kg/m2 had similar complication rates to the other cohorts but were more likely to require continuous veno-venous haemodialysis (51% vs 25-40% in other cohorts, P = 0.002). Overall survival to discharge was 48% (n = 207/431) with no differences between the cohorts (P = 0.92). Patients with BMI ≥35 kg/m2 had considerably lower survival (10%) in extracorporeal membrane oxygenation cardiopulmonary resuscitation compared with the other groups (P = 0.17). On multivariable logistic regression, BMI was not significantly associated with failure to survive to discharge. In conclusion, with the rising global prevalence of obesity, the results of our study suggest that clinicians need not treat obesity as a negative prognostic factor in cardiogenic shock requiring ECLS.

Neuron-Specific Enolase Levels in Adults Under Venoarterial Extracorporeal Membrane Oxygenation

We aimed to determine if elevations in serum neuron-specific enolase are associated with brain injury and outcomes in adults who require venoarterial extracorporeal membrane oxygenation. Prospective observational study. Two ICUs of a university hospital, Paris, France. Consecutive adult patients treated with venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock or in-hospital refractory cardiac arrest. None. Serum sampled 1, 3, and 7 days after venoarterial extracorporeal membrane oxygenation cannulation was stored at -80°C and neuron-specific enolase concentrations were measured in batches at the end of the study. The association between neuron-specific enolase concentrations and outcomes (28-d mortality and poor outcome, defined by a score of 4-6 on the modified Rankin scale at 90 d) were explored by multivariable logistic regression, with neuron-specific enolase concentrations dichotomized according to median values. One-hundred three patients were included, of whom 26 (25%) received preextracorporeal membrane oxygenation cardiopulmonary resuscitation. Median (interquartile range) day-1, day-3, and day-7 neuron-specific enolase serum concentrations were 37 μg/L (26-51 μg/L), 25 μg/L (19-37) μg/L, and 22 μg/L (17-31 μg/L). After adjustment for Simplified Acute Physiology Score II, preextracorporeal membrane oxygenation cardiopulmonary resuscitation, and Sepsis Organ Failure Assessment score at time of cannulation, a day-3 neuron-specific enolase greater than 25 μg/L remained independently associated with 28-day mortality (adjusted odds ratio, 4.98; 95% CI, 1.86-13.32) and poor outcome at 90 days (adjusted odds ratio, 4.63; 95% CI, 1.81-11.84). A day-3 neuron-specific enolase threshold greater than 80 μg/L had a 100% specificity for prediction of both mortality (95% CI, 92-100%) and poor functional outcome (95% CI, 89-100%). In a subset of patients who underwent brain CT, neuron-specific enolase concentrations were significantly higher in patients diagnosed with stroke, as compared with those without stroke. In adult patients under venoarterial extracorporeal membrane oxygenation, day-3 serum neuron-specific enolase concentrations are independently associated with short-term mortality and poor functional outcomes. These findings deserve validation in a multicenter setting.

Use of extracorporeal membrane oxygenation in postcardiotomy pediatric patients: parameters affecting survival

We aimed to investigate the risk factors affecting survival after extracorporeal membrane oxygenation use in pediatric postcardiotomy patients. One hundred thirty-three consecutive patients who underwent surgery for congenital heart disease who needed extracorporeal membrane oxygenation support were retrospectively analyzed. In all, 3,082 patients were operated, of which 140 patients (4.54% of the total number of operations) needed extracorporeal membrane oxygenation. Eighty (60.1%) patients were successfully weaned and 51 (38.3%) patients were discharged. Of the 50 patients discharged during the mean follow-up period of 34.8 (0-192.4) months, 6 (12%) patients died. The extracorporeal membrane oxygenation support was instituted in 29 (21.8%) patients for extracorporeal membrane oxygenation cardiopulmonary resuscitation, in 44 (33.1%) patients due to the inability to be separated from cardiopulmonary bypass, in 19 (14.3%) patients due to respiratory failure, and in 41 patients due to low cardiac output syndrome. Eighty patients (60.2%) were successfully weaned from extracorporeal membrane oxygenation support. The remaining 53 (39.8%) patients died on extracorporeal membrane oxygenation. Mortality was observed in 29 (21.8%) of the 80 patients in the successful weaning group, while the remaining 51 (38.3%) patients were discharged from the hospital. Multivariate analysis showed that double-ventricular physiology increased the rate of successful weaning (odds ratio: 3.4, 95% confidence interval lower: 1.5 and upper: 8, p = 0.004) and prolonged extracorporeal membrane oxygenation durations were a risk factor in successful weaning (odds ratio: 0.9, 95% confidence interval lower: 0.8 and upper: 0.9, p = 0.007). The parameters affecting mortality were the presence of syndrome (odds ratio: 3.8, 95% confidence interval lower: 1.0 and upper: 14.9, p = 0.05), single-ventricular physiology (odds ratio: 5.3, 95% confidence interval lower: 1.8 and upper: 15.3, p = 0.002), and the need for a second extracorporeal membrane oxygenation (odds ratio: 12.9, 95% confidence interval lower: 1.6 and upper: 104.2, p = 0.02). While 1-year survival was 15.2% and 3-year survival was 12.1% in patients with single-ventricular physiology, the respective survival rates were 43.9% and 40.8%. Parameters affecting mortality after extracorporeal membrane oxygenation support in pediatric postcardiotomy patient group were the presence of a syndrome, multiple runs of extracorporeal membrane oxygenation, and single-ventricular physiology. Timing of extracorporeal membrane oxygenation initiation, appropriate patient selection, appropriate reintervention or reoperation for patients with correctable pathology, the use of an appropriate cannulation strategy in single-ventricle patients, management of shunt flow, and appropriate interventions to reduce the incidence of complications play key roles in improving survival.

ICU nurses and ecpr

Introduction: Mortality from refractory cardiac arrest is greater than 90%. Survival may be significantly improved with Extracorporeal Membrane Oxygenation Cardio Pulmonary Resuscitation (ECPR). Objectives: To enable ICU nurses to participate in the ECPR team by preparing the ECPR trolley and/or console. Additional goals: maintain 66% ECPR accreditation following May 2016; plan ECPR nursing training at approximately 2 per month; and maintain ECPR outcomes comparable to reported rates. Methods: Training for nurses commenced May 2015. There were 10 planned sessions employing didactic explanations and simulated demonstrations. From 2016 to 2019 there were approximately two sessions per month booked. Additional hig- fidelity multidisciplinary simulations were provided by the Simulation Coordinator involving ED, Ambulance and Interventional Cardiology staff. Audits of ECMO outcomes were conducted biannually with comparisons made to international registries and literature. Results: By May 2016 greater than 66% of ECMO nurses had been accredited for ECPR. This rate was maintained and is currently 69/84 (82%). Of the planned education sessions from 2015 to 2018; the following were respectively documented as achieved 4/10, 13/23, 10/18 and 13/21. ECPR outcome from 2015-2018 was 39% survival to hospital discharge. Accredited ICU ECPR nurses were assigned every day to the ECPR team and attend ECPR emergency calls as they occurred. Conclusion: It is feasible for ICU nurses to participate as valuable members of the ECPR team. Whilst the potential numbers of patients in NSW who may require ECPR per year for refractory cardiac arrest may remain relatively low (i.e approximately 130/yr) it appears that the possible improvement in survival outcome for this group may be significantly increased from dismal to around 30%. The ICU ECMO ECPR nurse's role in assisting with this survival benefit for the patient is an important part of the function of the team.

Extracorporeal membrane oxygenation cardiopulmonary resuscitation, a luxury we cannot afford missing: a narrative review

Extracorporeal membrane oxygenation (ECMO) was introduced into practice since more than four decades to support patients with advanced yet potentially reversible cardiopulmonary failure. Following several prospective clinical trials, ECMO is considered a widely accepted support modality in severe neonatal respiratory failure and in pediatric cardiac failure, particularly in the perioperative environment. Compared with conventional CPR, ECPR provides higher level of cardiac output support and several potential advantages including a higher rate of successful ROSC, support of post-resuscitation cardiogenic shock while arranging and performing coronary interventions and maintaining organ perfusion during recovery of native cardiac output.

Cardiopulmonary resuscitation in children

To summarize recent advances in pediatric cardiopulmonary arrest prevention, resuscitation and postresuscitation management. Pediatric cardiac arrest has traditionally been considered a futile medical condition with dismal outcomes. Data in the 21st century indicate that more than 25% of children treated for in-hospital cardiac arrests survive to hospital discharge and more than 10% of children older than 1 year treated for out-of-hospital cardiac arrests survive to hospital discharge. These data establish that children are more likely to survive to hospital discharge than adults after both in-hospital and out-of-hospital cardiac arrests. Before arrest, exciting new studies demonstrate that the implementation of in-hospital pediatric medical emergency teams is associated with significant decreases in cardiac arrest incidence and overall pediatric hospital mortality. During arrest, ventricular fibrillation or ventricular tachycardia, once thought to be rare in children, occurs during 25% of inhospital pediatric cardiac arrests and at least 7% of out-of-hospital pediatric cardiac arrests. Survival to hospital discharge is much more likely after arrests with a first documented rhythm of ventricular fibrillation or ventricular tachycardia than after pulseless electric activity and asystole. However, ventricular fibrillation or ventricular tachycardia is not always a favorable rhythm, as survival to discharge is much less likely when ventricular fibrillation or ventricular tachycardia occurs during resuscitation from an arrest with the first documented rhythm of pulseless electric activity or asystole. Further, extracorporeal membrane oxygenation cardiopulmonary resuscitation appears promising under special resuscitation circumstances to improve outcome from highly selected in-hospital pediatric cardiac arrest victims. Further, postresuscitation interventions such as goal-directed therapies and therapeutic hypothermia have been demonstrated in adults and infants to improve outcome for selected cardiac arrest victims and are promising candidate targets for study in children. Pediatric cardiac arrest is not a futile condition; many children are successfully resuscitated each year. The implementation of new prearrest, intraarrest and postresuscitative therapies has the potential to further improve survival rates following pediatric cardiac arrest.

Pediatric Cardiopulmonary Resuscitation: Advances in Science, Techniques, and Outcomes

More than 25% of children survive to hospital discharge after in-hospital cardiac arrests, and 5% to 10% survive after out-of-hospital cardiac arrests. This review of pediatric cardiopulmonary resuscitation addresses the epidemiology of pediatric cardiac arrests, mechanisms of coronary blood flow during cardiopulmonary resuscitation, the 4 phases of cardiac arrest resuscitation, appropriate interventions during each phase, special resuscitation circumstances, extracorporeal membrane oxygenation cardiopulmonary resuscitation, and quality of cardiopulmonary resuscitation. The key elements of pathophysiology that impact and match the timing, intensity, duration, and variability of the hypoxic-ischemic insult to evidence-based interventions are reviewed. Exciting discoveries in basic and applied-science laboratories are now relevant for specific subpopulations of pediatric cardiac arrest victims and circumstances (eg, ventricular fibrillation, neonates, congenital heart disease, extracorporeal cardiopulmonary resuscitation). Improving the quality of interventions is increasingly recognized as a key factor for improving outcomes. Evolving training strategies include simulation training, just-in-time and just-in-place training, and crisis-team training. The difficult issue of when to discontinue resuscitative efforts is addressed. Outcomes from pediatric cardiac arrests are improving. Advances in resuscitation science and state-of-the-art implementation techniques provide the opportunity for further improvement in outcomes among children after cardiac arrest.